Managing Offload Delays Is a Multi-National Issue

Thursday, July 28, 2011

A.J. Heightman, MPA, EMT-P

Teresa McCallion, EMT-B

This report comes from the 2011 Pinnacle Conference in Miami Beach, Fla.

Kevin Smith, Deputy Chief of Niagara (Ontario) EMS, started off his lecture at the 2011 Pinnacle Conference in Miami Beach by telling the audience something they already were well aware of: EMS crews are being held hostage in emergency departments waiting to offload their patients. And, worse yet, offload delays are eating up resources and costing their system millions of dollars.

His session at Pinnacle focused on the Niagara EMS System’s experience and what steps they have taken, and continue to take to reduce off-load times in their emergency departments.

The Niagara EMS Region is located in Ontario near Niagara Falls (Canada) between Lake Ontario (to the North), Lake Erie (to the South) and New York to the East. There is no trauma center in the region. There are three primary receiving hospitals.

The issueIn 2005, Niagara Region EMS crews spent less than 1% of their patient time in offload delays. But with several hospital changes and restructuring in several hospital delivery systems, those times began to dramatically escalate. By 2010, offload delays had jumped to 21%, representing almost 10,000 hours of lost productivity.

Trend: Off-load delays by year for Niagara Region EMS2005 – <1,000 hours of drop off time delay = 1% of total crew time2006 – 2639 hours of drop off time delay = 5% of total crew time2007– 4274 hours of drop off time delay = 9% of total crew time2008 – 7079 hours of drop off time delay = 16% of total crew time2009 – 5939 hours of drop off time delay = 14% of total crew time2010– 9059 hours of drop off time delay = 21% of total crew time

An analysis of offload delays by month showed that, in a number of incidents, the crews spent from 3.5 to eight hours per call at the hospital. The impact began to really hit resources. At times, there were less than three units available for the 1,800-square kilometer service area. So, the Niagara Region began to work diligently to identify, study and rectify the situation.

What worked well:
• Determining the motivating factor for change:
• Transforming the process: make sure it’s the right change.
• Solid leadership
• Organization behavior: everyone needs to buy into it.

Process Improvements by Niagara RegionMotivation: When pigeons roosted and soiled a ED garage entrance area at one hospital, the Ministry of Labor actually came in and shut down the unhealthy ED entrance. Previous attempts to rectify the problem, fell on deaf ears until it became a health hazard.

Motivation is a factor, but in and of itself, it’s not enough. There needs to be people who have the ability to make a change and an understanding of situational factors. For example, the offloading delay was due to a lack of beds at long-term facilities. Patients were being kept in the hospital waiting for these beds, causing a trickle down effect in the emergency department.

Transforming the process: Using the “LEAN Healthcare Process”, based on the Toyota production process, Niagara EMS and the hospitals were able to clearly define the problem. The goal of the process is to eliminate waste. Through this process, they identified what they can do for patients to their service more efficient and provided value.

Components of the process include: Standardization: Everyone must follow the process in the same way regardless of shift.

Value stream mapping: By looking at all the processes from beginning to end, they were able to get together with all the people involved and break the problem down into smaller, more solvable problems.

Kaizen event: Through this process, they identified a key event that can be targeted for improvement. In this case it was triage.

SolutionsOffload nurse: One solution was the use of an offload nurse at each facility who is solely dedicated to EMS patients. Some funding was received from the government to cover costs, but it only provided a nurse for eight hours a day at the busiest receiving hospitals. At her peak, she can only handle four patients at a time.

Alert algorithm: Niagara EMS also created an algorithm to alert the hospitals when offloading delays were reaching a critical point. The system, cribbed from Calgary EMS, is based on yellow, orange and red coding. Orange indicates that there are four or fewer ambulances available in the EMS system. “I am happy to say we haven’t had a red alert,” Smith says.

Under an orange alert, EMS crews are cleared to leave the patient and stretcher at the hospital. Spare stretchers are stashed at the hospital, allowing crews to quickly get back into service. “I know it sounds a little hard, but we got buy in from the hospital,” he says.

An overcapacity protocol allows the hospitals to alert EMS if there is a delay on their end. However, with only three emergency departments in the system, there are limited alternative places to take patients.

Transfer of care monitoring: A new program that has only just recently been launched is looking at transfer care hours instead of offload delays alone. Using an automated system, the paramedics now swipe cards when they enter the ED, the nurse and paramedic each swipe their respective cards when the patient is triaged and again when transfer of care has officially occurred. The co-swiping enhances accountability.

Kiosks, located strategically throughout the emergency department also display transfer of care data on a monitor. Color-coding makes it easy to see problem areas. If a patient has not been transferred in under 60 minutes, the line for that patient turns red. Pink indicates a patient has arrived at the hospital, but has not been triaged. Green means triage has occurred and the time waiting for transfer of care is under 30 minutes. When patient care is complete and both the nurse and paramedic have swiped their cards, the color turns to gray. Dispatch is also monitoring the data, so they are aware when a crew should be back in service.

OMEGA dispatch protocol: In an attempt to decrease the number of patients EMS transports to the emergency department, Omega responses will be provided other options instead of transport to the hospital.

Phase One, including a retrospective study of patient outcome data, has been recently completed.

Looking at use of community paramedics: For a targeted population, they are developing a work plan for deployment of Community Paramedics. “We are doing a slow approach to it,” Smith says. They believe it is a good idea, but want to take an evidence-based approach. The concern is that they will be adding more work and losing track of their primary function.

Off-load delay oversight committee: The committee includes high-level officials such at a representative from the Board of Public Health, hospital CEOs and EMS chiefs, to assure a high accountability.

A 65-minute benchmark was established and, every month, the committee meets with the goal of reducing delay times by five minutes until the ultimate goal of 30 minutes has been reached.

Smith says the changes they have implemented are still relatively new and the overall data doesn’t yet show much improvement. However, comparative results indicate improvements in individual hospitals. The next step will be to look at specific quality improvements that seem to be making an impact on offloading delays. “The issue isn’t solved. We still have offloading delays, but we have seen improved performance,” he says.